EPIPEN – DIRECT PURCHASER ACTION

CLASS MEMBER INFORMATION

Company Name: *

First and Last Name of Company Representative: *

Company Street Address - Line 1: *

Company Street Address - Line 2:

City: *

State: *

Zip Code: *

Email Address of Company Representative: *

Telephone Number: *

CLASS MEMBER REPRESENTATIVE INFORMATION

Please list the contact information for the person responsible for overseeing the claims process and communicating about your claim and distribution of any settlement payments. If the information is the same as above, check the box below and skip to purchase information.

Same as Class Member Information.

Company Name: *

First and Last Name of Company Representative: *

Company Street Address - Line 1: *

Company Street Address - Line 2:

City: *

State: *

Zip Code: *

Email Address of Company Representative: *

Telephone Number: *

Brand EpiPen (Sold by Mylan)
49502-500-92
49502-500-02
49502-500-01
49502-501-92
49502-501-02
49502-501-01
Authorized Generic EpiPen (Sold by Mylan)
49502-102-02
49502-101-02
49502-101-01
49502-102-01
Generic EpiPen (Sold by Teva)
00093-5985-27
00093-5986-27
00093-5985-19
00093-5986-19

BRAND PURCHASE INFORMATION

Total number of units (i.e. packages of 2 EpiPen) of brand EpiPen purchased directly from Mylan between March 13, 2014 and February 6, 2025, reduced to account for returns and assignments.

Units of Brand EpiPen:

GENERIC PURCHASE INFORMATION

Total number of units (i.e. packages of 2 EpiPen) of Authorized Generic EpiPen purchased directly from Mylan between March 13, 2014 and February 6, 2025, reduced to account for returns and assignments.

Units of Authorized Generic EpiPen:

Total number of units (i.e. packages of 2 EpiPen) of Generic EpiPen purchased directly from Mylan between March 13, 2014 and February 6, 2025, reduced to account for returns and assignments.

Units of Generic EpiPen:

ASSIGNMENTS

Please check here if you are filing this claim based on an assignment:

If you are submitting a claim pursuant to an assignment, please identify with particularity that assignment below.

Please also attach documentation in support of such assignment, including the assignment agreement and purchase records showing your qualifying purchases from your assignor that are covered by any such assignment .

The Settlement Administrator may require additional information and documents for any claim made based on an assignment. If you are submitting this claim as an assignee, the data and supporting purchase records may be shared with the relevant assignor(s) during the claims administration process. By submitting a claim by virtue of an assignment, you agree that such data and documentation, and calculations based on such data and documentation, may be shared with your assignor.

WIRE TRANSFER INFORMATION

If you wish to have your share of the Net Settlement Fund paid by wire transfer, please provide the information below:

Bank Name *

Bank Address *

Account Name *

Account No. *

ABA/Routing No. *

Special Instructions *

Must Click Add To Submit Your Info.

Bank Name

Bank Address

Account Name

Account No.

ABA/Routing No.

Special Instructions

Action

DOCUMENTATION UPLOAD

Please upload records showing your qualifying purchases to support your claim.

*If you are submitting a claim pursuant to an assignment, please upload documentation in support of such assignment, including the assignment agreement and purchase records showing your qualifying purchases from your assignor that are covered by any such assignment.

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Files To Be Uploaded	Size	Action

SIGNATURE

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct to the best of my knowledge. I understand that the punishment for perjury varies by state, but perjury is a felony and carries a possible prison sentence of at least one year, plus fines and probation.

Signature: *

Company Name: *

Position at Company: *

SECURITY CHECK

Select Day Of Week For Filing: *

Select the Animal From the List of Items: *